Contributions and Challenges of Psychodynamic Play Therapy- With Foster Children and Their Many Parents

Introduction

The contribution of the article to the clinical and research discusson on psychodynamics

• In this article we have decribed the clinical contribution of psychodynamic play therapy to the treatment of foster children and we have pointed out the adaptations necessary, taking into consideration the cumulative trauma experienced in childhood, the insecure attachments, and the trauma of being removed from their home to foster placement.

• In this article there is an emphasis on the applications of the modes of rehabilitation of trust in the fostered children. This is accomplished by facilitating experiences of control in the child’s life and validation of the traumatic reactivations and reenactments. This also includes the identification of anxieties and conflict, which sometimes manifest in paucity of repetitive play together with play that may also be violent, aggressive, violent, and chaotic.

• The article emphasizes the importance of supervision provided to therapists practicing psychodynamic play therapy with foster children

Mother, the lullaby that you sang to me a long time ago, pursues me, and where shall I run to, where?

If I could, I would forget how I came here.

Mother, I am unable to escape your spells, my sight has darkened suddenly. If only I could, I would return to you today!

In this article we will describe the important contributions that are proposed by the psychodynamic approach to play therapy with foster children. The article was written in consideration of the paucity of literature on the subject of the treatment of foster children in Israel.

2. Fosterhood-A Special Form of Parenting

Fostering is a special form of transient parenting that provides caretaking for a child, whose parents do not have the capacities to care for them adequately. It provides the child with a family and emotional experience with benevolent attachment figures. Fostering is a complex process in which the fostering parents cares for a child who usually comes from a childhood that is colored by negative and traumatic family experiences [1]. The fosterhood is meant to provide the child with a warm protective home, and with conditions that are beneficial to their physical and emotional development. The uniqueness of the fosterhood lies in the fact that foster parents raise the child without their being their biological parents and without their being their only parents. The current conception in fosterhood encourages a continued relationship and physical meetings with the biological parents, to preserve and strengthen the childs relationship with their parents and with their families.

3. Childhood Trauma in Fostered Children

Children arrive in foster families after having experienced deficient and defective parenting, neglect, emotional abuse, physical or sexual violence, or the death of their caretakers. These traumatic experiences are usually accompanied by feelings of helplessness, loss of control, rupture and loss of relationships and loss of meanng and even annihilation anxieties. The difficulties of a child who has experienced injuries from one of his main caretakers, is more complex than single-event trauma and are related to the incapacity of parents to protect them, to care for them and to fulfuil their basic needs. There is disruption of the caretaking function and the child experiences uncertainty and terror that may occur suddenly and unexpectedly. They are at the mercy of their parents; intermittently cared for and intermittently abandoned or abused. The child experiences guilt, fury, shame, helplessness, and confusion. These deep injuries force the child to activate and employ powerful defence mechanisms that make it difficult to establish a basic feeling of stability and safety in their relationships with others [2]. Consequently, frequently these children of fosterhood have difficulty in acquiring basic trust in adults and in creating emotional and social bonds.

The exposure to trauma in childhood is connected to the injury of attachment and the completion of developmental milestones. The children are at higher risk to develop post traumatic disturbances because of the injuries that they experienced from their primary objects of attachment [3]. In the transition to the foster family, they experience an additional traumatic separation. A child that is moved to a foster family is distanced from their parents, siblings, extended family, and friends. They are forced to leave their familiar home and environment. The child experiences loss, mourning and uncertainty regarding their future. Many children view the transition to a foster family as destabilizing and it stirs up much anxiety. The adaptation of the child to their removal from their home depnds very much on their background and their history of attachment [4,5].

4. Attachment among Children in Fosterhood

Attachment theory deals with the importance of the environment for the development of the child and with the recognition of the primary need for the infant to be in a relationship with a parental figure. According to this approach, the infant has an inborn mechanism that governs the process of attachment and its aim is to ensure proximity to a caretaking figure to acquire and ensure protection, stress reduction and efficient coping with difficulties. These central parental functions servesthe infant and comprise a “secure base” from which they may distance themselves to explore their environment and to which they may return in moments of distress [6].

There are four styles of attachment: Secure attachment that characterizes a child that experiences their parents as available and responsive appropriately to their needs, with whom they feel secure. They then can develop social relations and cope with frustrating situations and stress efficiently. Ambivalent (or anxious-preoccupied) attachment in which the child attempts to stay close to their parents, act out for attention, resist soothing, but also cling to the parent and feel insecure about exploring their world; An avoidant style of attachment characterizes a child that experiences anxiety and lack of confidence in a parent but attempts to acquire relatedness by constant and demanding attempts to maintain proximity with them. A disorganized attachment style characterizes cases wherein the parent is the source of terror and pressure, and the child lacks a consistent and clear coping mechanism and experiences each event as unexpected and develops difficulties in regulating their impulses [7].

Children also become attached to caretaking figures who are not benevolent towards them. Separating from them is a difficult experience for the child and it is accompanied by feelings of disruption and guilt and possibley even an impairment of their future capacity for attachment (Slonim-Nevo Wallender, 2004). Attachment theory contends that the sense of security or its absence, in the early relationship between a child and their parent will be reflected in the child’s lifelong relationships. The whole relationship between the child and their biological family influences their attachment to their foster families. The more the child accumulated early negative experiences and developed an internal model of a neglectful and abusive attachment relationship, the more they are likely to see themselves as less worthy of protections and they will then have difficulty in developing secure attachments with foster parents [8].

The increased attempts of the foster parents to encourage secure attachment may threaten the child and lead to regressive behavior and even aggressive behavior, since the attempts to become closer arouses responses that are related to prior attachment figures who were abusive and disappointing. In addition, these attempts also contradict the internal negative model that the child internalized with regard to themselves.They do not expect at all to enjoy a protective and satisfying relationship [9]. Foster parents frequently have difficulty in coping with situations in which the child responds to them from within their injured models of attachment. The response of the child may evoke negative reactions from the foster parent that then confirms the previous experience of their prior internal model. The expectation for attachment on the part of the child and the tendency to view their reservations as lack of gratitude, can indicate the foster parents deficient understanding of the disturbance in attachment from which the child suffers. This requires holding and continued closeness despite the resistances that they demonstrate [10].

A substitute parental figure that persists in creating a consistent and continuous relationship may rehabilitate the damage caused by insecure attachment in childhood. The process of modifying the model of attachment is a slow gradual process, and foster parents should demonstrate patience towards the child and should accept the evolving process in the children [11]. Consequently, the children in foster care are referred for treatment that includes continuous guidance for foster parents [12].

5. Psychodynamic Play Therapy

The psychodynamic viewpoint emphasizes the importance of the internal world, the dynamic interplay between the various parts of the mind, the internalized object representations and their reactivation in play and their manifestations in the therapeutic relationship. This approach views the child as an entity, encompassing their mental and emotional experiences, the intensity of their impulses, the characteristics of which they suffer, their defensive organizations towards anxieties, their perceptions of themselves and their caretakers and the relationships between them [13].

There are two principles that stand at the basis of psychodynamic psychotherapy in children–The one is the need to enable the child to express themselves through the medium of play, and to bring forth their internal world, it wishes anxieties and phantasies, in an authentic manner. In their expression of their internal world with a person with whom they are close, a transformation ensues, of dissociated and anxiety evoking elements in their minds. By means of this process, these elements are accessed by internal processes of symbolization and thought and they enrich the contacts of the child with the other and enhances their coping with reality.

The second principle involves the recognition that this expression will emerge and evolve only in the presence of an attentive therapist who will in their presence, accompany the child empathically, while they are experiencing their internal world. The child is frightened by their internal world that can be overwhelming and chaotic. The presence and participation of the therapist strengthens the child and helps them to bestow symbolic and communicative expressions. In view of the benign and benevolent empathic presence of the therapist, the child is enabled to relax their defence mechanisms that disturb or limit them and to find in their stead other creative ways that can provide them with defence for themselves; Aided in this way they can express their inner world while enjoying a satisfactory relationship with the other. The capacity to be spontaneous and to initiate while knowing the other and enjoying their understanding, is the heart of psychodynamic psychotherapy (Cohen and Golomb, 2010).

The therapeutic encounter encourages expression of needs, deficits, feelings, conflicts, and attachment patterns that did not receive adequate responses in encounters with parental figures and remained repressed in the internal life of the child and ultimately manifested in bodily and behavioral symptoms. The child transfers onto the therapist a complexity of real and imaginary relationships that they encountered previously and that they experienced in the past and that they continue to experience in the present. These transferential relationships become the subject of investigation and are addressed in the therapy and serve as the main instrument in the process of change that unfolds in their minds. The therapist also finds themselves in an intense emotional relationship with the child in their care. In contrast to the transfence relationship of the child that develops towards the therapist and is projected on them, the countertransference evolves by the experiences that the therapist experiences and undergoes with the child and also derives from the therapist’s own internal world. The recognition of the various emotions that the therapist experiences is a very valuable asset and is employed as a technique of psychotherapy. Their experiences are a very essential source of information regarding the internal life of the child and their needs, and contain a special potential for change and for development of their emotional world [14].

The psychodynamic encounter with children is enriched by the richness of play and evolves by means of it, to a great extent. Play is a form of adaptation of defenses and creativity. It enables the child to cope with a variety of subjects such as conflicts, developmental demands, deprivation, loss, and various dimensions deriving from and comprising the circle of life. The symbolic play of the child in the therapeutic session connects their internal phantasies with events that they experience in the present (Kulka, 2002).

Klein viewed play as a natural expression of the child by means of which they translate, symbolically, anxieties and unconscious phantasies [15]. She interpreted the play directly and viewed it as parallel to free associations. In her view, raising the contents to consciousness leads the child to be less overwhelmed and enables them to cope with conflicts rather than to repress them. In therapy, the therapist provides the child with meaning for his aggression, and thereby a mental space is established wherein there is attentiveness and response to their communication to the therapist. This communication is accomplished by means of symbolic play and by means of projective identification–such as in partial splitting of the bad and aggressive parts of the self and their projection onto the therapist (Segel, 1979).

Bion expanded the concept of projective identification from the internal processes to the the interpersonal processes and described the therapeutic change that evolves when the therapist uses their internal capacity as a container to absorb and contain unbearable intense emotions of the child that are projected into the therapist [16]. The containment is accomplished by means of accepting these emotions, enabling their lingering in the therapist (containment) and then processing them in a way by which they become less threatening (neutralization and metaboliziation) and then by their return to the child by means of an intervention whereby the child can accept them without them being threatening to the child (Bot-Spillius, 2001). In Winnicott’s definition [14], the play found in the potential space that exists between the internal experience and that of the real world, enables the child to find themselves in phantasy and reality simultaneously. The potential space comes into existence during the early experiences of the child with their mother and depends on her availability at the critical stages of separation from her. The greater the confidence and security, the child is enabled to enter the imaginative, potential space in which they may develop and become creative and are able to abide in a place where their internal world and unconscious can exist without being threatened (Winnicott, 2004).

The bridge that play enables between the inside and outside, the internal and external, may breakdown in traumatic situations. Children who experience extended trauma, separations, and losses, have difficulty in entering the potential space where play provides, important experiences for the heathy emotional development (Lachman, 1996). Traumatic states generate feelings of loss of control, not knowing and helplessness. The blurring between the inside and external reality leads to a breakdown in the capacity to symbolize and collapse of the ability for playfulness. The dimension of phantasy becomes limited and does not enable the child to distance themselves from reality to return and to process it [17].

6. The Lack of Ability to Play Manifests in Two Forms

In their being silenced in reality and their being silenced in the sphere of imagination. In the first dimension the child is unable to engage in “Imaginative play” that enables them to distance themselves from it and to detach themselves from reality. This play is characterized by repetition, lack of connection to reality with a narrative or without any changes in action for a long period of time. In the second form, the child fears indulging imaginatively in order to avoid contact with their internal world. This child is unable to participate in dramatic play, has difficulty in attributing imaginative qualities to play figures, and their thinking is concrete (Lachman, 1996). The lack of playfulness will be identifiable frequently by means of the countertransference of the therapist. Boredom, tiredness, emptiness, limitedness and being stuck, when experienced by the therapist are signs of the absence of playfulness (Alvarez, 2005).

In these situations, the aim of the therapy becomes the retrieval and reactivation of the capacity to play, and only after that is accomplished, will the processing of the trauma be enabled. To this aim, the therapist may offer themselves as a significant figure in the world of the child, via the therapeutic relationship,as a figure that is containing and holding, that protects them, from the demands of reality and from the emotional storms in their minds (Bion, 2003). The “basic fault” among whoever experienced a deep and primary mental emotional injury and breakdown can be corrected and alleviated by a framework of therapy that is stable and reliable (Balint, 2008). This framework entails clearly circumscribed and clear boundaries in contrast to the trauma and losses experienced by children referred for treatment. The continuous presence of the therapist, with stable times and locations (setting) creates a mental and emotional container that is stable in face of daily interferences and convey a therapeutic message of continuity rather than disruptions that the child experiences. The child will internalize the therapeutic figure as someone whose presence is assured and upon whom one can rely (Fechler, 2015). This internalization will comprise a corrective emotional experience in contrast with the arbitrariness and losses the fostered child experienced.

The contributions of the the psychodynamic approach to play therapy among fostered children will be illustrated by the following case illustration.

7. Case Illustration

7.1 Neta’s Personal and family background

Seven-year-old Neta was referred for therapy due to outbursts of fury and anxieties. The referral was initiated by a social worker who was the consultant for the foster grandparents in the framework of the foster service. Neta’s mother is an alcoholic, and her father was violent towards her mother prior to his leaving the home, when Neta was 3 years old. Neta suffered from neglect and erratic discontinuous parenting. Reports accumulated from the nursery-school teacher of deficiencies in care for her basic needs (Nutrition, hygiene), and from neighbors who reported that she wandered around the neighborhood late at night unsupervised. After repeated failures to enroll the mother into an alcohol addiction program with a social work follow up, it was decided by the committee for treatment intervention programs, to move the five-year-old Neta and her younger sister to the foster care guardianship of their grandparents who expressed their willingness and commitment to raise them.

Neta needed to adjust to a totally new framework both in terms of its being in a new location and its different character (From the urban center to the periphery, from a city to a farming community), and being with grandparents whom she met only occasionally, over the years. She began to call her grandfather “father” and her grandmother “mother” and displayed inappropriate closeness towards strangers. This behavior increased the concern of her being exploited and abused. In addition, she hoarded sweets, had startle responses, and feared noises and she was afaid to fall asleep at night. She would share her bed with her younger sister, feigning concern for her, while during the day she would behave aggressively towards her. In general, she was agitated and restless and when her wishes were not met, she would respond by screaming and crying. In addition, Neta tried desperately to please her grandmother and grandfather, behaved adhesively and overly close to them, and attempted to please them and make them happy by drawing them many pictures. It was clear that they served as an anchor and source of stability for her, and any signs of displeasure in their behavior towards her increased her fears of abandonment and aroused her fears for their health. The grandparents made attempts to provide her with reinforcements and a sense of security, though at times they were impatient towards her and revealed their weariness in view of their age and also in view of Neta’s restlessness and the many outbursts that characterized her.

7.2 The Therapeutic Process

Neta attended a weekly psychoanalytic psychotherapy session provided by the Foster Service at the Summit Institute in Jerusalem. Prior to her meeting with Neta, the therapist met the foster grandparents for an interview, an intake, to assess Neta’s personal and family background. The grandparents shared their motivations in accepting their foster role, their complex experiences as grandparents who served parental roles, and they shared the difficulties that Neta encountered. In these sessions, the therapist worked towards establishing a therapeutic alliance with the foster grandparents, hoping to gain their confidence and to mobilize them to support Neta’s treatment. In parallel, she attempted to establish a relationship with Neta’s parents, but she was not able to do so. Neta’s father avoided contact with her. Her mother expressed interest but was unable to attend any of the planned sessions and could be reached occasionally, for telephone conversations.

Neta arrived at the first session, accompanied by her grandmother. She huddled closely to her grandmother, clinging, and attaching herself to her stomach and she appeared frightened. Despite her skinny and fragile appearance, the therapist could discern that this was in striking contrast to the power of her gaze. To alleviate her anxiety, the therapist introduced herself and added that she had met with the grandparents and that she knew that Neta now lives with them and not with her mother or father. Neta looked at her with curiosity and asked who else comes to the room. The therapist answered that she meets with other children who live in foster homes but not with their parents. She added that they will meet weekly on the same day and at the same hour, and that Neta can play, create, and talk about things of her choice and that thereby they will be able to better understand the things that happened in the past and that are happening then. The therapist mentioned to Neta that her grandmother will wait for her ouside the room and asked for her agreement. Neta agreed but left the room together with her grandmother to check where she will wait for her during the session. When she returned to the room there was palpable tension. The therapist showed her the toys and games in the room. Alongside the concern with the unfamiliarity of the situation, it appeared that Neta was overwhelmed and wanted to “use” everything that was in the room. She impulsively flitted between the various toys and games. Initially she opened the medical kit and doctor’s instruments, then the the eating utensils, scanned the board games and then scattered lego on the floor.

The therapist understood her agitation and her flitting movements between the games as a manifestion of the emotional storm and the panic that Neta experienced on attending the session.

Neta then discovered the doll house in the room and began to reorganize it. For the first time during the session, she became involved in one activity and sank into it and focused on it for some time. She stood the small figures outside of the house and put them in a row, scrutinized each one and then holding two of them she asked if could take them with her. The therapist answered her that it was not possible to take things outside of the room, but that she would look after the figures and that she would ensure that Neta could play with them when she visits for sessions in the future. In her sensitive answer, the therapist felt that she had disappointed Neta, even though Neta did not show any reponse and continued in her play. The exchange between them at the beginning of the next session, confirmed the feelings and intuition of the therapist:

Neta: (On entering) Where are the dolls?
Therapist: You’re looking for the dolls that I took care of for you? You are perhaps anxious that you will not find them…
Here, they are in the doll box.
Neta: (Examined the box to see if the small dolls were there) Let no one touch them!
Therapist: You would like to have them all for yourself! I am looking after them for you.

The therapist felt that Neta was testing her abiliy to trust her and to feel safe in the therapy session. Neta’s anxiety and her feeling that she only trusts herself were palpable in the room and manifested also towards the end of the sessions. In response to the words of the therapist that ten minutes remained until the termination of the session, Neta would leave the room to check if her grandmother was truly waiting for her. When she discovered that her grandmother was not there, she returned to the room looking very worried. The therapist reflected and acknowledged Neta’s concern that her grandmother was not waiting nearby but added that there still were a few minutes until the end of the session and that she would take care of her until grandmother arrives. Neta moved around the room restlessly and settled down only when her grandmother appeared. The therapist felt tense, anxious, and helpless because of Neta’s concern and anxiety. She doubted her own ability to alleviate Neta’s anxiety and to fulfil the role of a caretaking figure that looks after and protects her. She imagined the many occasions that Neta had been forgotten at the nursery school, when her parents did not arrive to fetch her, and she felt heartbroken. The supervisor helped the therapist expand her therapeutic understanding and to view Neta’s behavior as a reflection and expression of something that was unfolding inside her and not only as a response that reflected the injuries that she experienced in reality.

As the therapy progressed, a repetitive pattern appeared in the sessions. When Neta would enter the room, she would scan its contents and requested to play with the doll house. When responded to in the affirmative, she emptied its contents and began to reorganize the household objects and the figures in the house. The therapist viewed the emptying of the house nad its reorganization as Neta’s way of coping with the experience of loss of her home, both in its physical and emotional dimensions. She identified Neta’s need for a space, for a “mental and emotional home”, in which she could feel secure, protected, and free to develop, in contrast with the internal trauma that she had experienced. The therapist was curious to see how the symbolic play would develop, but the organization of the doll house became a ceremony that repeated itself and was conducted in the same way exactly at each session. The therapist observed from the side and began to feel boredom and stuck. Even though Neta played with the dollhouse and the figures, there was no story line, conversation or interaction between the figures or verbal or emotional expression. The appeared to be no development between sessions. The therapist felt that Neta does not need her, does not acknowledge her and that there is no connection between them. Only after some time did the therapist understand that the repetitive play, in its repetition and rigidity, with her observing, was not really play. In the supervision, a connection was made between the feelings of tiredness and exhaustion that the therapist experienced, to the lack of playfulness of Neta. She was directed to intervene and to appropriate time for the ceremony in view of the understanding that because of the lack in Neta’s ability to play, she needed to create a space that will enable play. The development of the ability of the therapist to contain these negative feelings and her intervention, activated by allotting a time limit to the activity, enabled a further development in the therapy. Over time Neta began to feel secure to express herself and to expand her activity and the playful content in the room.

“Mother’s milk”–The need for nutrition, feeding and existential survival.

As the therapy progressed, Neta frequently expressed her difficulty to maintain an imaginative playful state and tended to escape to the the dimension of reality and concreteness. She began to express the existential need for feeding and her anxieties regarding the fulfillment of her primary needs.

Neta: This doll is hungry. We must give her milk so she does not die. Do you have milk?
Therapist: Milk? No, I don’t have any milk here. And you are telling me that she needs some.
Neta: Okay… What are we going to do? (She searches the play materials). Bring the white glue. It is similar. (She asks hesitantly) Can I pour it into the bottle?
Therapist: Yes
Neta: (Pours the glue and mumbles to herself). The milk will stick, and she will not be hungry any more!

The therapist was confused and frustrated as she was not able to fulfill Neta’s needs. Her concrete answer (There is no milk”) she understood, aided by the supervision, was a disruption of the play mode and space, by her introducing reality. She identified the negative overwhelming feelings that she experienced in the counter transference in contrast to Neta’s passionate wish that she become her mother and that she save her from death. The expression of this wish led Neta to reexperience her past rejections and threats.

The therapist even acknowledged the initiative and rich creativity invested in the solution that Neta found (Glue rather than milk) alongside her survival response and the way she relied on herself to meet her own needs. The glue symbolized the wish for nourishment and the constant nourishment of the deprivations on the one hand and the stickiness of the material that was undigestible on the other hand.

On another occasion Neta requested that her therapist prepare her a drink of cocoa. The therapist asked her if she wants real cocoa, not play. Neta answered in the affirmative. For the next session the therapist prepared a bottle of cocoa in advance. Neta was very happy to find it, drank the cocoa with lust, covered two dolls with a blanket and said: “They are tired and need to sleep their father killed their mother and they need to be cared for”. In her words Neta exposed how her inner life was saturated with violence and the confusion between her drives and her wishes to feel satisfied. They also indicate the proximity of her annihilation anxieties to the fulfillment of her needs. The therapist was frightened by the weighty responsibility bestowed upon her, but tried as much as she could to absorb the difficult content and to contain it. The therapist’s urge to respond to Neta’s need to be nourished in a concrete form, led to greater depth in the supervision. It was understood that in so doing, the therapist attempted to respond to, and fill Neta’s primary needs and thereby to transform the therapy room and the relationship to the therapist to one that was secure and safe. She had the notion that if that were accomplished then Neta would develop an ability to receive positive nutrition from her human environment, initially in a concrete way and then later symbolically. The therapist gradually developed a therapeutic attitude in which she was attentive to Neta’s emotional expressions and the symbolic meaning conveyed and thus was not focused on solving problems realistically or in the alleviation of her difficulties in her adjustment to the therapy. Here it is important to emphasize that the repeated encounter with the deficiencies of her attachment, not met adequately in her early development, and the inevitable separations, presented a formidable emotional challenge for her treatment and this issue comprises a challenge in the treatment of many children in foster care.

7.3 The Tenacious Struggle For a Safe Space

The doll house acquired a centerpiece in the treatment, and the ceremony and organization of the house began to develop into play that symbolized a struggle for a place in the home. The therapist noted both the content of the game and also its process. She was attentive to the flow of the game as an indicator of Neta’s internal state of mind, and she tried to identify the conflict that occupied Neta and the patterns of the internal object relations.

Neta: (Trying to push the doll into the house while the people inside threw her out)
Therapist: They are not letting her inside!
Neta: (Pushes the doll into the house forcefully while struggling with the people inside)
Therapist: That is insulting
Neta: (Starts to throw chairs and other objects at the people. She becomes very aggressive and violent) Bring the police! Let them take them all to jail!

The therapist felt the injury and insult of the rejection. The struggle at the entrance to the house reflected the underminining of basice trust, and the therapist felt the need to express the emotions that arose. On occasion Neta introduced a doll that represented a sister, and angrily told her that it is a pity she was born and commanded her to leave the home. Occasionally the dolls were surrounded by policemen, and they protected the dolls inside. The therapist tried to follow the events in the play and quite oftent felt overwhelmed and confused. She acknowledged Neta’s need to feel protected and to have a sense of belonging. In the supervision, she aquired understanding of the way Neta internalized the representation of the policeman and their role in securing justice and order and to guard and protect her.

Neta: Here are their parents. They came to save them. Open the door!
Therapist: They surely are very excited. I am opening the door…
Neta: Now kill them! They are not really the parents!
Therapist: You want me to kill them because they are not the real parents! That sounds scary! So, who are they?
Neta: They are satanic monsters! But soon they will come to life and will live. There is a special powder.

Neta began to expose deeper levels of confusional anxiety and helplessness regarding the parental caretaker figures. In her play she conveyed the terror and confusion that she experienced when the parentlal figures suddenly transformed into monsters, threatening her, rejecting her and ejecting her from the original family home. Her murderous phantasies appeared as she was fighting for her own survival! Her play was chaotic. Benevolent figures protecting and guarding were transformed in a moment to evil monstrous figures. The female doll who struggled against them they locked in the house. Neta could not tolerate her helplessness and after an exhausting struggle she killed the figures and after a while brought them back to life. In view of the terror and uncertainty that she felt, her need for control was essential for surviving the internal struggles that manifested in her play. In addition, a conflict was apparent, between the wish to feel at peace and protected within the walls of the house and the experience of being alert to danger and the constant awareness of danger in the house. Regarding the therapeutic relationship Neta’s play symbolized the yearning to succumb to the current relationship with the therapist on the one hand and the deep fears of being hurt by it, on the other hand.

The eroding battle for survival in the room, evoked feelings of terror and paralysis in the therapist. Neta dicated a rigid script and forcefully directed the therapist to play it out according to her detailed instructions. The therapist yielded to her demands and did not question them. The supervision aided the therapist to get to know, through the content and process, and while taking the transference into consideration, the inner conflicts and insecure attachments that Neta was plagued with. Her play was heavy, serious, rigid but also frivolous. Its content dealt mainly with separations from the important figures in her life and with existential anxieties. As the therapeutic relationship developed, the therapy helped the therapist to understand this and to become more active, cautiously, in conversation and in play, and to help Neta process the emotional content. The therapist took the roles of the figures as Neta commanded her, and she began to express via them feelings such as helplessness, fear and pain, in order to give legitimacy to the emotional expression that arises in experiences that are paralysing and terrifying.

At times Neta’s symbolic play was changed to competitive board games, but then, when Neta was about to lose, she changed the rules to her advantage. After changing the rules, the therapist discerned a reduction in Neta’s negative emotional arousal, and this reduction enabled Neta to regain her sense of control and to avoid losing the game. She understood that it was important for Neta to win at any cost, at that time, but she wondered whether to ignore this modification and to allow it or to restate and reinstate the rules of the game. Through the supervision, the therapist understood that Neta had not achieved a sufficient degree of control and self regulation and so she experienced the frustration and the anxiety in losing the game, very intensely. Neta experienced the loss as undermining her self concept, and this experience evoked in her, feelings of humiliation and rage. In that situation and at that stage, the game involved a sense of survival for her like any interpersonal interaction. Her response to losing a game led her to activate grandiose defences in order to preserve her fragile feelings of self worth, emanating from her narcissistic deficits.

Staying with and bearing painful spheres With the progress of the therapy, dysphoric affects began to appear together with expressions of anger and aggression.

Neta: Oh how hungry she is! Bring the Ambulance!
Therapist: Here it is, it’s arriving. Where is she?
Neta: She is already dead. She needs to be buried.
Therapist: That is very sad. It is so difficult to lose someone close

The uncertainty regarding Neta’s capacity for rehabilitation and the intense pain that she experienced manifested in her symbolic play. Medical teams began to appear in her play in order to save various figures but mostly failed in their roles and the experience of loss was very painful. The therapist reflected how heartbreaking it is to lose someone close, and it appeared that Neta was attentive while she contined to play with the ambulance alongside the doll that died. It appeared that even though she expressed yearnings to resuscitate the parental objects in unconscious phantasy and to be in their arms, they were actually dead in her inner world. This game reenacted the trauma of neglect and the annihilation anxieties that she had experienced in her past.

Gradually Neta began to give expression in her symbolic play to her feelings of anger towards protective figures who became disappointing and confusing. Occasionally, at unexpected moments without a detectable cause, Neta angrily took the toy rifle and shot the therapist. The therapist felt confused and uncertain as how to respond and so played dead while she waited for Neta’s instructions, which took quite some time to be delivered. After a period of time, Neta ordered her to get up.

This scene repeated itself. By attending to the rigidity in Neta’s behavior and the pressure that she applied, the therapist was able to interpret to Neta that she was angry. Neta was attentive to the words of the therapist and at times would respond angrily; “Quiet!” and then sometimes she would throw the magic dust onto the therapist to revive her. It appeared that in these moments Neta experienced schizo-paranoid anxieties and consequently a need arose in her to attack, destroy and annihilate the therapist and then to revive her by omnipotent means. This game displayed the split inside and lack of integration that characterized Neta– On the one hand the representation of the therapist as a bad and threatening object, and on the other hand, a representation of a benevolent object wishing for her well-being. Recognizing this helped the therapist to yield and adopt a benevolent role and to respond more and more flexibly. Gradually the game became less threatening, due to these responses.

7.4 A Space for Reflection and for Integration

As the therapy progressed and the confidence and trust in the relationship increased, Neta began to express narratives of cure and recovery. She no longer needed the ceremony of reorganizing the doll house, and the theme of starvation, threat and danger in the home appeared less frequently and these were replaced by games with the eating utensils. Instead of basic nutrition with milk she was able to enjoy gourmet food that she prepared, cooked and baked. Both the manner of playing and its content became less rigid and the space of activity increased significantly. Though themes of competition on the part of Neta towards the therapist still featured, it appeared that her need for control was noticeably reduced and she was able to tolerate the experience of losing in a game. The therapist felt that Neta was building her ego strength to cope with the frustruations that previously were intolerable for her.

When the therapist attempted to understand Neta’s feelings and inquired about them, Neta frequently answered that she did not know what she felt or irritably reprimanded the therapist for “digging” too much. The therapist felt that Neta was no longer excessively anxious to please her and succeeded in expressing her anger towards her. The supervision that was focused on the internal space of the therapist enabled her to be in contact with the difficult emotions tht arose inside of her and aided her in expanding and deeping her emotional abilities to bear the negative experiences that Neta brought with her into the treatment relationship. This containment enabled the therapist to transform and ameliorate the threatening aspects of these feelings for Neta. Consequently, via the process of projection identification, these feelings were returned to Neta after having been transformed, neutralized, metabolized and given validation and meaning to her experiences. Over the course of the therapeutic relationship and process there was content that Neta brought that was destructive and split and there currently a development that indicated her increasing capacity to contain her inner world and the reality of her life with four parents.

7.5 The Therapeutic Encounter with the Foster Parents

Neta’s treatment was accompanied by meetings with the foster grandparents. At the beginning of the therapy the grandparents were concerned about Netas behavior and wondered why she did not have “normal” behavior. It was appararent that they, like Neta, were in need of basic primary holding. The therapist helped them realize thae reality that children like Neta encounter difficulties in viewing their foster parents as a source of security; they are anxious and had experienced many disappointments in the past and so test the new relationships. This acknowledgement was essential for the grandparents and accompanied the meetings. When asked about her relationships with Neta’s parents, the grandparents mentioned that the father does not manage to arrive consistently at the mothly meetings. They described how Neta looks forward to meeting him, is excited in anticipation of the meeting and is disappointed at his non-arrival. The mother comes to visit on weekends but is prone to angry outbursts and when encountering and witnessing this, Neta anxiously clings to her grandparents.

The experience of the grandparents was tense and conflictual. They were angry at the mother’s inability to overcome her addiction and to raise her daughters and were frustrated with Neta’s outbursts, but nevertheless they felt guilt and compassion towards them. In the parallel process, the therapist felt anger towards the grandparent’s inability to understand Neta’s pain and predicament, while also feeling compassion and empathy towards them and their coping with the challenges of the situation. Acknowledgement of these feeling within the supervision process, helped the therapist to validate her split feelings and the complex experience of Neta’s grandparents.

Discussion

The psychodynamic approach to child psychotherapy illustrated in this article proposes substantive contributions to the treatment of children in foster care. It expands the significance of the injuries emanating from insecure attachment, from early trauma and from the traumatic removal from the primary home and emphasizes the subjective experience of the child and details their internal feelings and experience. It acknowledges the defenses that the injured child develops in face of the severe emotional and mental pain and the distortions that they create in the mind and view of external reality. Treatment by means of this approach enables the child to free themselves from defense mechanisms that block them from reengaging with benevolent caretakers. It facilitates real change in their internal alignment and in the manner in which they experience their lives. In addition, this approach expands and deepens the emotional ability of therapists to bear the destruction and severe losses that the child brings with them to the therapeutic relationship, and thereby lies its main contribution (Cohen, 2001).

From the time of her birth Neta experienced discontinuous, neglectful care and severe injury to her primary attachment. The experience of abandonment was fundamental to her identity and to her self-perception of the world and to her relationships with others. The primary attachment to her parents made it difficult for her to become attached to her grandparents and established a pattern of ambivalent and anxious attachment. Consequently, Neta could not trust adults in her environment and suffered from difficulties in separating. The traumatic childhood experiences and her removal from her childhood home and her placemnt into a foster home led Neta to develop emotional and behavioral difficulties which led her to be referred for treatment.

The initial aim of Neta’s therapy was the creation of a therapeutic alliance based on trust. The paradox in Neta’s treatment, was similar to that of other victims of trauma, in the fact that the treatment necessitated the creation of a trusting relationship with a person whose trust of others had been undermined basically and significantly. Consequently, building trust is a given aim and not a precondition for treatment (Harmen, 1994). Considerable patience was necessary to establish trust in the therapeutic relationship. Neta needed to understand that the therapist would survive even though her internal world was saturated with aggression and that she would fulfill her primary needs. Neta’s deep injuries challenged the trust in the therapeutic relationship and was tested repeatedly and it obligated the therapist to extend the parameters of the treatment beyond the familiar and routine. In parallel, the therapist created an alliance with her grandparents and mobilized them to support the therapy (Cohen, 2017).

The early traumas that Neta experienced undermined her capacity for imaginative play. Her capacity for a temporary “suspension of belief” was inhibited at the beginning of the therapy, and her play was repetitive and forced. The therapist, aided by her supervision, offered herself increasingly to Neta, as another who could participate in Neta’s phantasy world and looked after her consistently, in a containing and holding therapeutic relationship, sheltering her from the demands of reality and from her internal storms (Bion, 2003; Cohen, 2001). The more the trust and security were established, the more Neta was able to enter the playful potential space. The play enabled her to relive and reenact traumatic elements, to express aggression and to allow herself to address conflictual content. Even though there were difficult disassociated experiences, the therapist validated feelings such as fear, pain, loss and confusion and helped Neta to create some order in her internal world, rife with aggression, storms and confusion (Shepherd, 2013). The therapist aimed to provide Neta with a secure space. She enabled her to choose and lead, responded to her wishes and alleviated her anxieties. In lieu of her empathy and the support she received in her supervision, Neta felt over time, more capable and less destructive (Ben Shlomo, 2018).

Neta, alike many fostered children, experienced trauma whose origins were abandonment, and consequently, separations undermine them and arouse anxiety and guil. In this case illustration, a separation took place at the end of each session, to which Neta reacted with anxiety from further abandonment. When the themes of separation and loss were relived in the treatment, the therapist verbalized the significance and meaning of the experience. The separation from Neta will come about at the termination of the treatment process. It is important that the therapist not save Neta from experiencing or alleviating the pain, neither to deaden it or cover it up, as happened in Neta’s past.

The meetings with the foster grandparents were described briefly, as we chose the focus on Neta’s experience. Expansion will be possible in a further article, especially regarding the complexity that characterizes foster parenting of this nature.

Conclusions and Practical Applications

Psychodynamic psychotherapy with fostered children requires a particular orientation. Usually, therapy is long-term, and its aim is to develop trust in the relationship. Many foster children see their caretakers as abusive and threatening because of the rigid defense systems that they have developed (Drewes, 2014). They learn to trust themselves only, have difficulty in expressing neediness or a wish for relatedness and may suspiciously test their therapists. On occasion, a child will unconsciously do all in his ability to reject the therapist and in so doing will reenact their past experiences of the “bad object”. This internal drama may be relived intensely in the therapeutic encounter. The change is enabled by means of the capacities of the therapist to bear, contain, and neutralize the toxic mental contents and to return them to the child in a form that they may be able to internalize [18].

The encounter with foster children challenges therapists because of their intense emotions. The therapeutic working through of pain in children touches unconscious worlds of the therapist and arouses in them intense responses (Luria, 2002). Consequently, there is a great necessity for parallel supervision sessions that can provide space in which these experiences can be raised, and reflected upon, while addressing the therapists unresolved conflicts that are stirred up. This prevents impasses due to fortification of defenses and disassociation which can then affect the patient negatively. A system that includes containment and support enables and enhances the patient’s self expression while providing a benevolent therapeutic environment (Cohen, 2001).

In a benevolent environment, a foster child may meet the other–a therapist who enables them to express their emotional needs and helps them to return and to connect to the hidden hopes inside them and to the belief in their inner strengths [19]. The benefits of a benevolent psychotherapy may enable a corrective emotional experience that is internalized and that will serve as a balance to the arbitrary experiences and the tragic losses that the foster child has experienced. They will consequently be enabled, to find themselves, to accept themselves and to live more at peace with themselves (Fechler, 2015).

Statements & Declarations

Conflict of Interest Statement

The authors declares that she has no conflict of interest.

Competing Interest
The authors has no financial or non-financial interests that are directly or indirectly related to the work submitted for publication.

Funding
Not applicable.

Data Availability Statement
Not applicable.

Ethics Approval
This is a clinical & theoretical paper.

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